Neoplastic Conditions

Primary neoplastic conditions of the vagina are relatively rare.

Benign tumours: benign vaginal tumours include squamous papilloma and a variety of benign mesenchymal tumours, the commonest of which is leiomyoma.

Malignant tumours: the most common primary malignant tumour by far to arise within the vagina is squamous carcinoma. However, primary squamous carcinomas of the vagina are rare and much less common than spread from a primary tumour arising elsewhere, e.g., cervix, uterus, urinary bladder or rectum. If the tumour also involves the cervix then it is most likely to be of cervical origin. Pre-invasive vaginal squamous lesions also occur. They often coexist with CIN lesions within the cervix and with dysplastic lesions elsewhere in the lower female genital tract, e.g., vulva. They are categorised as vaginal intraepithelial neoplasia (VAIN) and graded I to III, similar to the grading system used for CIN. These may be identified at colposcopic examination during investigation of an abnormal cervical smear. Adenocarcinomas rarely arise as a primary lesion within the vagina. A type of vaginal adenocarcinoma (clear cell carcinoma) may be associated with in-utero exposure to diethylstilboestrol. Other malignant tumours of the vagina include adenosquamous carcinoma, malignant melanoma and a variety of malignant mesenchymal lesions. The aetiological factors in the pathogenesis of vaginal squamous carcinoma are broadly similar to those implicated in the pathogenesis of the corresponding cervical lesions. Previous pelvic irradiation and a history of preinvasive or invasive disease are predisposing factors to squamous carcinomas of the vagina.

Treatment: benign vaginal lesions such as cysts and fibroepithelial polyps are usually removed by biopsy. Benign mesenchymal tumours should be excised preferably with a rim of uninvolved tissue in order to avoid local recurrence. Surgical treatment of early-stage malignant vaginal tumours is radical hysterectomy. Further treatment, usually in the form of radiotherapy or chemoradiation, is then dependent on staging and these cases should be discussed at a multidisci-plinary gynaecological oncology meeting. With advanced vaginal tumours, radiotherapy may be the initial treatment. Occasionally, recurrent vaginal tumour may be managed by vaginectomy (colpectomy).

Prognosis: the prognosis of malignant vaginal tumours largely depends on the FIGO staging. Tumours are staged by a combination of clinical and pathological parameters. Clinical assessment includes speculum examination, bimanual pelvic and rectal examinations, cystoscopy and proctosigmoidoscopy. Overall five-year survival is in the region of 40%. Other prognostic factors such as tumour grade, patient age and tumour localisation are of less prognostic significance.

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